Provider Demographics
NPI:1225681281
Name:FORRESTER, MADALYN
Entity Type:Individual
Prefix:
First Name:MADALYN
Middle Name:
Last Name:FORRESTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26795 CALLE REAL
Mailing Address - Street 2:
Mailing Address - City:CAPISTRANO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92624-1506
Mailing Address - Country:US
Mailing Address - Phone:949-412-6825
Mailing Address - Fax:
Practice Address - Street 1:17461 DERIAN AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5843
Practice Address - Country:US
Practice Address - Phone:949-412-6825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28489235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist